This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Tuesday, September 27, 2011

Reflections on Narcissus and AMCs

Narcissus was so entranced by a reflection of his own image that he was paralyzed into inaction by looking at it, leading to an unfortunate end. There is a lesson here for the country's academic medical centers (AMCs). These "crown jewels of American medicine" are lobbying to be exempt from certain federal budget cuts. As noted in a paid op-ed page advertisement in the New York Times,* they cite their special status as "urban medical centers treat[ing] patient populations with high rates of chronic disease, coexisting conditions, and more advanced stages of illness." They note that "physicians and scientists at teaching institutions are the foundation of biomedical research and innovation in medicine [where] they invent and improve surgical devices and . . . inform drug discovery and development." Finally, they remind us of their essential role in training the next generation of physicians.

All this, being true, is viewed by the ad's author and many of his peers as sufficient reason to inoculate the AMCs from possible cuts in graduate medical education (GME), the portion of the Medicare budget that funds residency training programs. But these statements fail to tell the story of how academic medicine, in many institutions, is failing the American public.

It does not, for example, explain why many AMCs have been slow to adopt proven tools of process improvement to reduce harm to patients and improve efficiency. Indeed, some "trophy" faculty members who are widely published in these arenas and assist such implementation in community hospitals have been known to be systematically ignored by their home institutions. Meanwhile, those who learn and do this work are saving hundreds of lives and millions of dollars.

It does not explain the persistent lack of transparency in many such institutions with regard to clinical outcomes, notwithstanding the documented value of such transparency in improving quality and safety. As noted by President Paul Wiles at Novant, "With our results in the public domain we have a real incentive to make our results better."

It does not explain why the medical schools that own or are affiliated with many AMCs have failed to train their students in how to use the scientific method to improve the delivery of care. As the Lucien Leape Institute notes: [M]edical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer.

It does not explain the huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine. Brent James describes this as, "well-documented massive variation in practice based on local medical myths." He notes:

We continue to rely on the "craft of medicine," in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.)

Compare this to the approach taken at the Mayo Clinic, where "the most important thing we can teach our residents and trainees is the value of standard work."

It does not explain the reluctance of many AMCs to engage patients and families in the design and delivery of care. Instead, customers might be treated as empty vessels, into which clinical decisions about testing and therapies are poured. The contrast with how things might work, as exemplified here, is stunning.

Raise these issues with people at many AMCs, and they, briefly looking away from their reflection, say, "You don't appreciate what we do."

Ah, we do appreciate it. We just think you can better.

It's time for the many slower moving AMCs to demonstrate your commitment to an improvement in the delivery of patient care. Make that part of your mission. Ensure that it is as scientifically valid and academically important to your faculty as new devices, drugs, diagnostic tests, and basic science journal articles. Show us that you can help integrate the care of your patients with primary care doctors, skilled nursing facilities, and rehabilitation centers as well as you run your transplant services, ICUs, and trauma centers. Demonstrate true patient and family involvement in the diagnostic and treatment decisions in you hospital.

Show us that this is all part of your GME program, and we'll be happy to keep paying the freight. Absent that, you are training doctors for the wrong future.

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* "Urban Teaching Hospitals Disproportionately Targeted for Medicare Cuts," Kenneth L Davis, President and CEO of The Mount Sinai Medical Center in New York City. September 27, 2011.

Anonymous - It is purely anecdotal evidence, as I have no knowledge of hospital advertising budgets. In Boston, there is a lot of advertising done by a few AMCs about how excellent their care is, without evidence to back up the claims.

As Clayton Christensen has said:" ...almost every significant disruptive innovation is unpopular with some constituents who benefit from the status quo."

Here we have institutions who not only refuse to adopt the innovations you cite, but also publicly lobby to maintain none other than - the status quo. We all know what Christensen postulates happens to such institutions in a period of disruptive innovation.

Paul, Great post, and so timely. As a member of leadership at a brand new academic medical center that is striving to provide excellence, efficiency, quality and access, as well as train our students and residents in all aspects of systems improvement, patient and family centered care, and innovation, our chair group was just discussing some of this today. The real problem is how to get from here (fee for service, productivity-based incentives) to there (totally integrated system that supports education, research and maintains excellent care) as the dollars shrink. We never thought about "opting out" of any cuts, but are constantly struggling to keep the patients as the focus and build our systems around them. No immediate answers, but clearly it must be done if American health care is to survive.

The AMCs are all too busy metastasizing their empires and constructing their referral network of smaller community hospitals that they have devoured, to be bothered with outcomes and process. Besides, better to maintain the status quo for those living off reputation.

Disruptive change often comes from those with the least resources who are outside of the system.. Group Health Cooperative (training facility for UW docs) designs all of their care "around the patient" is integrated system in Seattle that eliminated all of their hospitals. A few years ago they implemented a comprehensive EHR and last year shifted primary care to the medical home model. The result? Higher patient and provider satisfaction, and positive ROI - this year asked for a 0% increase from the insurance commissioner.

Now they have 30 minute visits and teams that care for those with chronic conditions and cutting both admission and readmission rates. This summer they even started to design their new clinics around the patients workflows and are eliminating or reducing waiting rooms. On did I mention up to 50% of all primary care visits happen remotely via email or telephone encounters?

Clearly we will still need hospitals but much of the care in the future will take place outside of the hospital walls and teaching hospitals can lead the way. If they don't they will simply be large empty buildings devoid of health and healing.